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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49772/psn-pdf
    October 01, 2016 - Lapse in Antibiotics Leads to Sepsis October 1, 2016 Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis The Case A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal pain, fevers, and short…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853080/psn-pdf
    August 30, 2023 - Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges August 30, 2023 Sanford K, Schuelke S, Lee M, et al. Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workf…
  3. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
    June 01, 2013 - Spotlight Case July 2008 Spotlight Case Emergency Error 1 2 Source and Credits This presentation is based on the June 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Nicholas Symons, MBChB, MSc, Imperial College London Editor, AHRQ WebM&M: Robe…
  4. psnet.ahrq.gov/web-mm/cups-error
    January 12, 2011 - Cups of Error Citation Text: Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…
  5. psnet.ahrq.gov/web-mm/situational-unawareness
    August 01, 2009 - Situational (Un)Awareness Citation Text: Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33838/psn-pdf
    July 01, 2017 - Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know? July 1, 2017 Studdert DM. Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know? PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/doctors-multiple-malpractice-claims-…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863641/psn-pdf
    February 28, 2024 - Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training February 28, 2024 Haugstetter M, Hines S, Sousane Z, et al. Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49580/psn-pdf
    March 21, 2009 - Medication Reconciliation Victory After an Avoidable Error March 21, 2009 Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error The Case A 91-year-old woman, previously active and indepen…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49453/psn-pdf
    July 01, 2004 - Bowel Prep July 1, 2004 Nelson D. Bowel Prep. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/bowel-prep The Case The patient is a 73-year-old woman who 20 years ago underwent treatment for breast cancer. At her daughter's suggestion, the patient requested referral for colonoscopy, as she understood there w…
  10. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.263_slideshow.ppt
    March 01, 2012 - Spotlight Case July 2008 Spotlight Case Postdischarge Follow-Up Phone Call * * Source and Credits This presentation is based on the March 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Michelle Mourad, MD, and Stephanie Rennke, MD; Divi…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865467/psn-pdf
    March 27, 2024 - I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences March 27, 2024 Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferenc…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33658/psn-pdf
    October 01, 2007 - In Conversation with...David Marx, JD October 1, 2007 In Conversation with..David Marx, JD. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd Editor's Note: An engineer and an attorney by training, David Marx, JD, is president of Outcome Engineering, a risk management firm. …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33813/psn-pdf
    August 01, 2016 - Safety In Dentistry August 1, 2016 Ramoni R, Walji MF, Kalenderian E. Safety In Dentistry. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/safety-dentistry Perspective In a famous scene from the 1976 film, Marathon Man, Laurence Olivier, playing dentist Dr. Christian Szell tortures Babe Levy (played by…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49680/psn-pdf
    March 01, 2013 - Pathologic Mistake March 1, 2013 Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/pathologic-mistake The Case A 32-year-old previously healthy woman experienced abdominal pain and bloating for 6 months. The discomfort worsened with eating. After losing 15 pounds …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49851/psn-pdf
    January 01, 2019 - One Bronchoscopy, Two Errors January 1, 2019 Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors The Case A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic respiratory failure…
  16. psnet.ahrq.gov/web-mm/did-we-forget-something
    April 28, 2021 - Did We Forget Something? Citation Text: Gibbs VC. Did We Forget Something?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
  17. psnet.ahrq.gov/web-mm/central-not-epidural
    August 28, 2024 - Central, not Epidural Citation Text: Simmons D. Central, not Epidural. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49724/psn-pdf
    January 01, 2015 - Bowel Injury After Laparoscopic Surgery January 1, 2015 Moorthy K. Bowel Injury After Laparoscopic Surgery. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery The Case A 30-year-old man presented to the hospital for a scheduled laparoscopic inguinal hernia repair with mes…
  19. psnet.ahrq.gov/web-mm/misplaced-vial-medication-kit-variability-contributes-medication-error-during-patient
    March 12, 2021 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport Citation Text: MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Q…
  20. psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
    August 30, 2023 - Strategies to Improve Organizational Health Literacy. Citation Text: Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format:…

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